The Purple World: Healing the Harm in American Health Care

Copyright © 2015 by Joseph Q. Jarvis

All rights reserved, including the right to reproduce this book, or portions thereof, in any form. No part of this book may be used or reproduced in any manner whatsoever without written permission from the author, except in the case of brief quotations embodied in critical articles and reviews. The views expressed herein are the responsibility of the author and do not necessarily represent the position of the publisher. For information or permission, write: joseph.jarvis@msn.com.

This is a work of creative nonfiction. The events herein are portrayed to the best of the author’s memory. While all the stories in this book are true, some names and identifying details may have been changed to protect the privacy of the people involved.

Editorial work and production management by Eschler Editing

Cover design by Brian Halley

Interior print design and layout by Marny K. Parkin

eBook design and layout by Marny K. Parkin

Published by Scrivener Books

First Edition: May 2018

ISBN 978-0-9986254-8-5 (Softcover)

To my daughter Caitlin H. Jarvis,

my colleague in advocacy

for better, simpler, cheaper health care for all Americans

Contents

Acknowledgments

Preface

Chapter One

What’s Golden in Medicine?

Chapter Two

Exploiting Pathology for Profit

Chapter Three

Prostitution and Health Insurance—The Similarities

Chapter Four

Changing US Health-Care Business as Usual: A Heavy Political Lift

Chapter Five

The Power of Constitutional Federalism and Perverse Incentives in US Health Care

Chapter Six

Rabies at the Laundry—Bipartisan Failure in Health Policy

Chapter Seven

Why Politicians Cannot Be Trusted

Chapter Eight

The Medical Industrial Complex: It’s All about the High-Priced Sale, Not the Patient

Chapter Nine

American Health Care: High Profit, Poor Quality

Chapter Ten

Red and Blue Health Policy Proposals—One and the Same

Chapter Eleven

Obamacare, Trumpcare, and Beyond

About the Author

Note to the Reader

Acknowledgments

Foremost I thank Annette W. Jarvis, my spouse, for her understanding and support of this passion of mine to heal the harm in American health care. Without Annette, none of my work on this issue leading to writing this book would have happened. I am also grateful to my children, who grew up listening to my health-policy rants and still forgive me. I am indebted to the many hundreds (thousands?) of patients through whom I have learned the practice of medicine. All doctors should humbly admit that their skill and knowledge is given as a gift to them by patients creating a debt that is never repaid. I have been blessed to work with three editors during the creation of this book. Crystal Liechty, who showed me how to give my story a meaningful shape, Kathy Jenkins, who smoothed the shape into readable prose, and Michele Preisendorf, who made that prose conform to the requirements of style. Eschler Editing and Scrivener Books, consummate professionals, for making sure this book is everything I hoped it would be and more. Leaders of the Physicians for a National Health Program (PNHP), including Cecile Rose, David Himmelstein, and Steffie Woolhandler, have taught me much of what I know about the failings of the health-insurance business model. Brent James, leader of quality improvement at Intermountain Health Care, has generously shared his insights and experience with me. The health reform proposal for Utah outlined in Chapter 11 was developed in conversation with Richard Passoth. I am deeply grateful to each of these people for their contributions to the effort that made this book possible.

Preface

On November 8, 2016, the United States of America entered a purple world. What had been considered a solid blue wall in presidential politics crumbled, creating what felt like the most significant change in American governance during my lifetime. I did not vote for Mr. Trump, so I can claim no victory. Nor did I vote for Ms. Clinton, and I don’t lament her loss. The American electorate became less reliably red or blue (in other words, it became more purple), and therefore much more unpredictable, more irascible, and more demanding of its government. That, I believe, is all to the good, though it is very uncertain what the electorate is demanding other than change.

A key issue in the 2016 election, a race with no real dominant policy domain, was health-care reform. That’s nothing new. Americans have been attempting health-system reform for at least fifty years. More recently, the repeal of Obamacare has been the battle cry of the red side of the political aisle in every congressional election during the Obama presidency. Mr. Trump joined that chorus. And what seemed to help turn the voting world purple was the stark rise in Obamacare health-insurance premiums, an increase that was announced during the period of early voting. Mr. Trump did not articulate anything cogent about the health-care policy during the campaign that he might pursue after election, but that didn’t matter: voters just knew that the health-care status quo, represented then by Ms. Clinton, was untenable. It’s hard to disagree with that.

This purple-world policy vacuum creates an opportunity. Unlike President Obama, who had hammered out a policy deal with the medical industrial complex before he was even sworn in to office, Mr. Trump is apparently not going to drive health policy. And Congress, the body that should legitimately be tending the purse strings of the federal government, and therefore the national policy, has a majority that seems unlikely to agree with itself. With the Democrats in Congress simply playing Obamacare defense and the Republicans unable to articulate exactly what repeal and replace should be, American patients may find themselves without recourse when in need of health-care financing.

The Affordable Care Act, on the other hand, anticipated a rising role for state-health policy innovation beginning in 2017. During that year, the California legislature actually considered comprehensive health-system reform legislation (SB 562), which was touted as single-payer reform. That bill passed the California Senate but was held up in the California Assembly, where ultimately a select committee issued a report rejecting it. Single-payer health reform refers to a proposed change in health policy in the United States. The current status has multiple payers for health care, both public (Medicare, Medicaid, CHIP, VA, Indian Health Service, etc.) and private (usually for-profit health insurance, but also HMOs, and BC/BS, which can be nonprofit). Single-payer health-system reform proposes to replace these multiple payers for health care with one, single paying entity in a given region (such as a state) or throughout the entire nation (Medicare for All). The state-health policy innovation made possible by the Affordable Care Act does not explicitly call for single-payer health-system reform, but it does not exclude it either. However, if a state, such as California, were to decide through legislation or ballot initiative to attempt single-payer health-system reform, an act of Congress enabling that reform would be essential. Likewise, single-payer health-system reform on the national level (Medicare for All) would require an act of Congress. Maybe this brave new purple world will finally offer a Tenth Amendment opportunity in health policy. That is what this book proposes.

I didn’t write it in the weeks after the election. It has been several decades since I began studying medicine and lived through the experiences I tell about in this book. Back then I had a native belief in the American way of government, which I had been taught was to be of, by, and for the people. But along the way I began to doubt.

I had patients in my family practice in the 1980s who simply could not afford the simplest prescription for a child’s earache. I know from observation that poor medical care can put even middle-income families outside the realm of American prosperity and leave them there for multiple generations. Despite what donated medicines and other resources I could cobble together for these families, they were hurting, and I could not do much about it. The Sisters of the Holy Cross, who made hospital care possible for my patients, did so at the cost of a burgeoning debt. Eventually they had to sell their hospital to a for-profit business, which removed any options in Salt Lake City for what was called indigent care. Government of, by, and for the people could not seem to provide care to many of its people, but government health programs seemed very able to make the medical industrial complex very profitable. The wonders of modern medicine and public health, which had been made possible largely through the combined efforts of all the people, were denied to millions, most of whom had paid the world’s highest tax rates to support clinical science and health-care delivery.

By the time the nuns sold their hospital in Salt Lake City, I had moved on in search of a public-health career that would make a difference. The early chapters of this book are about that search. After working in federal and state government and practicing medicine in academic medical centers in Colorado, Nevada, and the District of Columbia, I returned to Salt Lake City with serious doubts about whether American government at any level could really help American families with health-care problems. I did everything I could think of to draw attention to the plight of American patients who were overcharged while they were being both over- and under-cared for: I published op-ed pieces in most major Utah newspapers, did radio and TV interviews, lobbied the legislature, started a nonprofit health-policy advocacy group, ran for office twice, gave hundreds of speeches, attended political conventions and rallies, and helped on campaigns. But nothing changed. So I decided to write this book. I titled it The Purple World because I hope to persuade people to vote as unpredictable, irascible, purple-change agents rather than dyed-in-the-wool red and blue partisans.

And then November 8, 2016, happened. And the Purple World emerged.

Chapter One

What’s Golden in Medicine?

Iwas born during the so-called Golden Age of medicine. Well, at least some people thought it was golden. I’m not a medical historian, nor is this a book about the history of my profession, but it’s useful for people interested in modern medicine to contemplate how Western civilization came upon this vast and very expensive enterprise. And how it became so much more vast and expensive in the United States than anywhere else in the world. Nearly 20 percent of our American gross domestic product is spent on health care, while the average first-world country elsewhere in the world devotes about half that much economic productivity to health care. And they’re all measurably in better health than Americans. We’re spending about $3 trillion each year, about $1 trillion more than the rate spent by other wealthy nations, without anything to show for it. ¹

Many Americans have come to believe that we have the best health-care system in the world. Americans have a tendency to see themselves as the best in everything, so perhaps our assertion, self-serving as it is, simply belies our native jingoism. But no one, American or otherwise, can pretend that Americans invented modern medical science. That clearly happened in Europe, sometimes intentionally, other times serendipitously.

One biographer, Wendy Moore, asserted that a Scot, John Hunter, living in eighteenth-century London, invented the clinical science of surgery. At the age of twenty, he went to London to apprentice with his older brother, William, in his growing enterprise—an anatomy school. Would-be surgeons from around the British Empire were increasingly desirous to gain expertise in dissection, a skill set they could learn only from a teacher practiced in the craft who had access to cadavers.

John proved to be adept at both acquiring dead bodies and carving them up. His reputation as a body snatcher disgusted and intrigued the London populace, but his skill as a surgeon was even more widely acclaimed—he even attended the royal family. This combination of the sinister and the salubrious was said to have made John Hunter the model for Robert Louis Stevenson’s Strange Case of Dr. Jekyll and Mr. Hyde, published approximately a century after Hunter’s death.²

After becoming an expert anatomist, John Hunter launched himself into a surgical career, but with a difference. Rather than accept the then traditional methods of surgery, he insisted on observing his patients for evidence of what actually worked and then altering his practices of care to match what methods made for best patient outcomes. For example, during a tour of duty as an army surgeon during the Seven Years War (known as the French and Indian War in the American colonies), Hunter took advantage of a chance incident involving five captured French soldiers to make observations about war-wound healing. Each of these soldiers had sustained a wound during battle. Unable to retreat with their regiment as the British advanced, they hid out in an abandoned farmhouse for four days before being discovered. Because they were in hiding, no surgeon had operated on their wounds. Surgical tradition of the time required that bullet wounds be explored and enlarged. In the era prior to the discovery of antiseptic technique and long before antibiotics, infection was the universal result of probing war wounds, leading to catastrophic suppuration, sepsis, and death.

Hunter noted that the five French soldiers actually were healing better than if they’d been probed by a surgeon, and eventually healed completely—including the French soldier with a through-and-through chest wound. Thereafter, Hunter limited his wound exploration on the battlefield to those cases where bleeding was excessive or bone fragments were found. Generally, he did as little as possible and let nature do the healing. The results overcame the doubts of his detractors, who were clinging to the dictums of ancient practices like bloodletting.

In an era when bloodletting was considered a cure for everything from colds to smallpox, surgeon John Hunter was a medical innovator, an eccentric, and the person to whom anyone who has ever had surgery probably owes his or her life. A review of Moore’s biography of John Hunter printed in the New England Journal of Medicine agrees with Moore’s subtitle assessment of Dr. Hunter, stating, John Hunter is rightly regarded as the founder of scientific surgery. He died an old man after a long and successful career.³

Not so for Ignaz Semmelweis, the Austro-Hungarian obstetrician who first conducted observations that eventually made antiseptic practices common in medical care. Dr. Semmelweis took his medical training in Vienna and, after graduation in 1847, became an assistant to the chief professor of obstetrics at the Vienna General Hospital. There were two obstetrical services in the hospital: the first clinic was run by the physicians and had a maternal mortality rate of 10 percent due to puerperal fever (childbed fever), while the second clinic was run by midwives and had less than half that rate of maternal mortality. The difference in death rates was well-known, and women in labor literally begged to be admitted to the second clinic.

Dr. Semmelweis took the death toll of patients in his service personally. (One can only wish same were true of American doctors. American patients would be well served if our doctors paid close attention to the medical errors in hospitals that make preventable patient injury the fifth leading cause of death in our country. For instance, nearly half of all surgeries involve some kind of medication error or unintended drug side effect).

He began to consider how the care in the first clinic differed from that delivered in the second. In doing so, he was taking on then traditional and long-held views of medicine concerning the origin of disease, namely that imbalances in the patient’s four humors accounted for illness. Prior to the Semmelweis’s study of the different rates of disease between the two different obstetrical clinics, no one had considered the possibility that factors external to the patient might actually be causing disease. It was universally thought that patients got sick because there was something wrong with the patients.

The breakthrough for Dr. Semmelweis came when he noted that the postmortem findings of his good friend and fellow doctor, who died from an infection after he was accidently stabbed by a scalpel during an autopsy, were identical to those of patients who died from childbed fever.

He therefore postulated that something contagious existed in cadaverous materials and, noting that physicians—but not midwives—performed autopsies, believed he’d found the reason for the higher rate of childbed fever in the first clinic. As chief resident, he instituted a policy of handwashing with chlorinated lime before attending any living patients, and the rate of childbed fever in the first clinic dropped to zero, making Dr. Semmelweis the first practitioner of continuous quality improvement in health care.

However, his findings were not accepted by the Viennese medical establishment, and he was forced to resign his position and return to Hungary, his native land. There, he grew increasingly despondent about his failure to persuade physicians to wash their hands and was eventually placed in an asylum, where he died, ironically, of sepsis in 1865. (It should drive all of us crazy that we still have trouble persuading doctors to wash their hands often enough.) One of my infectious-disease professors in medical school, trying to emphasize the ubiquitous nature of microbial risk, once said that if urine were red and stool were blue, we would live in a purple world. That world is especially purple in hospitals, the place where infections—particularly those that are hard to treat—are most common in American communities.

Ultimately, Dr. Semmelweis’s ideas about handwashing gained acceptance in France and England, and then scientific credibility as first Dr. Pasteur in France and then Dr. Lister in England, elaborated on the germ theory of disease. Antiseptic technique revolutionized the care of patients and, for the first time, made it possible that the care of a physician was more likely to help than harm the patient.

By World War I, physicians were impressed enough with antiseptics that they began treating war wounds with the direct application of various antibacterial chemicals. Nonetheless, as observed by Captain Alexander Fleming, another Scotsman who’d received medical training in London, infected wounds were killing soldiers constantly. Dr. Fleming surmised that the antiseptic chemicals themselves were doing more harm than good. He documented that many disease-causing bacteria were hidden deep within wounds and not affected by the surface application of antiseptics.

His findings were ignored by his colleagues, who went about practicing medicine as they’d been taught without recognizing the harm they were doing. Most doctors practicing today in America are too busy to look at how their methods may be harming patients. By which I mean that they’re too distracted by the way we do